Questionnaire - Renzo Kaashoek

Intake Health Coaching + Orthomolecular Advising

This is an extensive questionnaire which helps me to get a clearer idea of your current lifestyle, diet and medical history, but also your goals and the challenges you’re facing. It will take about 10 minutes, but will save you and me a lot of time during our session and it will help us get to the practical side quicker. I’d like to ask you to carefully think about the questions and answer them where you can and where you feel comfortable.

I take measures to protect your information.

Thank you for your time,
Renzi!

Name

Last Name

Phone Number (if you'd like to get a call)

Gender

Female Male

Length (M)

Body Weight (KG)

Date Of Birth

Do you have symptoms or physical/mental discomforts? If so, please explain.

When did it start?

Are you diagnosed with disorders or disease? If so, please explain.

When did it start?

Do you eat a lot?

How often do you eat in a day? (Including all snacks)

Is it easy to skip a meal? Does it result in symptoms?

Do you often feel a strong urge to:

Sweet food Salty food Greasy food

What is your regular diet like?

Are you following a (temporary) diet? Please tell me more about it.

Feel free to upload your diet:

Are you following a vegan or vegetarian diet?

No Vegetarian Vegan

Do you eat fish and/or seafood? If so, is it wild fish/not farmed?

Do you have food intolerances or allergies? If so, please explain.

How is your digestion?

Do you often feel bloated? When especially?

Do you discharge the bowels daily? If not, after how many days?

Do you eat processed food? What and how much?

Do you consume sugar rich food regularly? If so, please explain

Do you drink coffee? If so, how much?

Do you drink alcohol?

Do you smoke?

Are you using or have you used antibiotics? If so, please explain.

Are you using medication? If so, what and how long for?

Are you taking supplements? If so, what supplements do you use?

Do you easily bruise and/or get sick?

Do you experience mood swings often? If so, please explain.

Do you move or exercise? What do you do and how often?

How often are you outside/in the sun?

Do you fall asleep easily?

How many hour of sleep do you get each night?

Do you wake up at night? How often?

How do you feel when you wake up in the morning?

What do you enjoy doing?

What would you rate your level of:

Can you handle stress and tension well? How do you deal with it?

Do you find it hard or easy to concentrate?

Do you struggle with feeling down, depression and/or anxiety?

What is your family situation like?

What work do you do?

How much do you think about your work outside of work?

Have you had your blood levels tested recently? Please ask or search for the results so we can discuss them.

Do you have a chronic disease or condition? If so, please explain.

Have you been on medication? If so, what and how long for?

When you look back at your health journey, what really stands out to you?

Are you pregnant or breast feeding?

Are you using or have you used birth control? If so what and how long for?

How good does your menstrual cycle flow?

Do you experience discomforts or irragularities during your menstrual period?

Are you in your menopause? If so, how long for?

What are the goals you'd like to achieve?

By when would you like to achieve them?

Why?

What is the biggest obstacle at the moment?

What questions do you have for me?

Please, let me know if there's something I should know ...

I understand and agree that I have and want to take responsibility over my own health and wellbeing

Intake Health Coaching + Orthomolecular Advising

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